WM0801194_Application_20221109

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.
1. Date: 11
2. County:
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Geological Resources, Inc. Telephone: [phone]
Applicant's Mailing Address: 3502 Haves Road, Monroe, NC 28110
Applicant's Email Address (if available): rtb(a'�geologicalresourcesinc.com
5. Contact Person (if different than Applicant): Rae Troiano Brown Telephone: [phone]
Contact Person's Mailing Address: 113 West Firetower Road, Winterville NC 28590
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Brunswick Vol Fire Dept Telephone: [phone]
Property Owner's Mailing Address: 1465 Vinson Blvd., Brunswick NC 28424
Property Owner's Email Address (if available): bvfd302(@yahoo.com
7. Property Physical Address (Including PIN Number) 1465 Vinson Blvd, PIN 0199.01-05-1850.000
City Brunswick County Columbus Zip Code 28424
8.
Reason for Well(s): ground water contamination assessment
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater
contamination, remediation, etc.)
9.
Type of facility or site for which the well(s) is(are) needed: retail petroleum facility
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
10.
Are there any current water quality permits or incidents associated with this facility or site?
If so, list permit and/or incident no(s).
Incident No. 43181, WM0801194
11.
Type of contaminants being monitored or recovered: petroleum
(ex: organics, nutrients, heavy metals, etc.)
12.
Are there any existing wells associated with the proposed well(s)? If yes, how many?
11
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0801194
13.
Distance from proposed well(s) to nearest known waste or pollution source (in feet):
100
14.
Are there any water supply wells located less than 500 feet from the proposed well(s)?
Yes
If yes, give distance(s): 400'
15.
Well Contractor: Geological Resources, Inc.
Certification No.: 3270A (Justin Radford)
Well Contractor Address: 3502 Haves Road, Monroe, NC 28110
PROPOSED WELL CONSTRUCTION INFORMATION
As required by 15A NCAC 02C .0105(f)(7), attach a well construction diagram of each well showing the following:
a. Borehole and well diameter e. Type of casing material and thickness
b. Estimated well depth f. Grout horizons
C. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals

Continued on Reverse
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured?
material: 1 Bolted manhole cover and locking well cap
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 11/22
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 12/22
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
a. All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections, streams, or lakes within 500 feet of the proposed well or well system.
b. All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
G. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.10B(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant hereby agrees that the proposed well(s) will be constructed in accordance with approved specifications and conditions of
this Well Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
Subchapter 2C) and accepts full responsibility for compliance with these rules
Project Manager, P.G.
Signature of Applicant or *Agent Title of Applicant or *Agent
Rae Troiano Brown * If signing as Agent, attach authorization agreement stating
Printed name of Applicant or *Agent that you have the authority to act as the Agent.
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the applicant to construct
wells as outlined in this Well Construction Permit application and that it shall be the responsibility of the applicant to ensure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
See attached RTE Brunswick Volunteer Fire Department
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources' Regional Office
Asheville Regional Office
2090 U.S. Highway 70
Raleigh Regional Office
Swannanoa, NC 28778
3800 Barrett Drive
Wilmington Regional Office
Phone: [phone]
Raleigh, NC 27609
127 Cardinal Drive Extension
Fax: [phone]
Phone: [phone]
Wilmington, NC 28405
Fax: [phone]
Phone: [phone]
Fayetteville Regional Office
Fax: [phone]
225 Green Street, Suite 714
Washington Regional Office
Fayetteville, NC 28301-5094
943 Washington Square Mall
Winston-Salem Regional Office
Phone: [phone]
Washington, NC 27889
450 W. Hanes Mill Road
Fax: [phone]
Phone: [phone]
Suite 300
Fax: [phone]
Winston-Salem, NC 27105
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

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TYPE 11 MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
CONCRETE P
GROUND SURFACE
0'-
GROUT CEMENT
SENTONITE SEAL
MANHOLE CO Vf R
Traffic bearing; flush mounted; domestic steel
,,—LOCKING WELL CAP
01
2 INCH DIAMETER
SCHEDULE 40 PVC CASING
(PROPOSED CASING LENGTH
OF 2 FEET
a.
TOP Of SEN TONI TE 2'865-
0.010 INCH SLOTTED
2 INCH DIAMETER
SCREEN SCHEDULE 40 PVC SCR
(PROPOSED SCREEN LENGTH
OF 10 fff-T
SAND f -1L TER PACK
PROPOSED WELL DEPTH 15'BGS END CAP
6
Geological Resources, Inc.
Time Saver #6
NC 130 / Vinson Blvd
Brunswick, Columbus County
GRI 4952
Note:
1. This diagram is not to scale.

RIGHT TO ENTER AGREEMENT RECEIVED NOV 04 2022
/ /'
FOR 5 2
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF COLUMBUS
We, the undersigned, being all of the fee simple owners of certain tracts or parcels designated as 62281
of the County of COLUMBUS, recognizing the benefits to said property by reason of conducting subsurface
investigations hereby grant to Yam City Oil & Gas Company and the agents the right to enter said property
in accordance with the requirements of the State of North Carolina. Yam City Oil & Gas Company agents
may include Geological Resources, Inc.
The undersigned hereby covenant and warrant that they are the sole owners of said property; that they
solely have the right to grant this right to enter for conducting subsurface investigations against the lawful
claims of all persons whomsoever.
It is agreed that Yam City Oil & Gas Company shall be responsible for restoring any damage done to the
ground of said property by its employees or its agents during the subsurface investigation and monitoring
period, and that Yam City Oil & Gas Company shall abandon monitoring wells on said property in
accordance with NCDEQ requirements at the conclusion of the monitoring period.
It is agreed that Yam City Oil & Gas Company shall hold harmless the owner of the aforementioned
property for any personal injury that might be sustained during the course of conducting or proximately
resulting from the conduct of subsurface investigations.
Right to Enter denied.
�✓ Right to Enter granted.
SignatwK
I �//7 --
Phone
Date
Printe Na
b I/ fJ 3 0 z ��� • ��-.
Email
3502 Hayes Road Monroe, North Carolina 28110
Phone [phone] [phone] • Fax [phone]